Submandibular intubation as an alternative for intra-operative airway management in maxillofacial fractures - our institutional experience

Abstract

Background and Aims:Airway management in anaesthesia for maxillofacial surgical procedures is tricky at times when the nasal/oral routes are contraindicated or are impossible. Tracheostomy as an alternative inherits its own complications. We present a case series of the submandibular route for tracheal intubation as an alternative.Methods:The procedure was performed in ten selected adult patients with maxillofacial/mandibular fractures associated with a fracture of skull base or nasal bone. All of them were medically stable with no need of intensive care or mechanical ventilation in post-operative period.Results:Submandibular intubation in all ten patients of panfacial fractures allowed uninterrupted surgical techniques with a secured airway. All patients were reverted to oro-tracheal tube at the end of surgery as immediate maxillomandibular fixation was not necessary. The patients were extubated after recovery from anaesthesia before they left the operating theatre. One patient in the post-operative period had a superficial infection of incision site that responded well to local treatment. No other complications were encountered in the intra-operative or post-operative period.Conclusion:In complex maxillofacial injuries, when oral or nasal intubation hampers surgeon's field of view, submandibular intubation offers an effective alternative to short-term tracheostomy along with small risk potential. There is a need to emphasise its regular application in such cases so that technique can be mastered by both surgeons and anaesthesiologist.

Controversies in the Management of the Airway in Panfacial Fractures. Literature review and Algorithm Proposal

“…After its development, it has been used as a first-choice technique for intra-operative airway management in complex maxillofacial injuries by some, with panfacial trauma being one of the most common indications for submental endotracheal intubation. (31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46) Patients are initially orotracheally intubated, and then the tube is passed through the anterior floor of mouth and reconnected to the ventilator. This allows access to the whole of the face without interference.…”

“…Among complications reported, the most significant were accidental extubation (31) or accidental perforation of the pilot balloon in 4.35% of cases (42). Other complications included wound infections, between 2-3.5% (37,41); transient lingual and marginal nerve paraesthesia; bleeding and submental hypertrophic scar 1.45%-3.57% (32,35); orocutaneous fistula; traumatic injuries to the submandibular and sublingual glands or ducts (36) or mucocele formation.…”

Experience with airway management and sequencing of repair of panfacial fractures: A single tertiary healthcare appraisal in Najran, Kingdom of Saudi Arabia - A retrospective study

“…[ 3 ] Literature search has revealed three cases of intracranial intubation with two cases in panfacial fractures[ 6 7 ] and one case in a premature neonate during routine nasotracheal intubation. [ 8 ] Other intubation options include submental,[ 3 ] submandibular,[ 9 10 11 ] retromandibular, and tracheostomy. [ 12 ] All these choices have their advantages and disadvantages.…”